DCP3

ORIGINAL ARTICLE

The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses

Stefan G. Hofmann • Anu Asnaani •

Imke J. J. Vonk • Alice T. Sawyer •

Angela Fang

Published online: 31 July 2012

� Springer Science+Business Media, LLC 2012

Abstract Cognitive behavioral therapy (CBT) refers to a

popular therapeutic approach that has been applied to a

variety of problems. The goal of this review was to provide

a comprehensive survey of meta-analyses examining the

efficacy of CBT. We identified 269 meta-analytic studies

and reviewed of those a representative sample of 106 meta-

analyses examining CBT for the following problems:

substance use disorder, schizophrenia and other psychotic

disorders, depression and dysthymia, bipolar disorder,

anxiety disorders, somatoform disorders, eating disorders,

insomnia, personality disorders, anger and aggression,

criminal behaviors, general stress, distress due to general

medical conditions, chronic pain and fatigue, distress

related to pregnancy complications and female hormonal

conditions. Additional meta-analytic reviews examined the

efficacy of CBT for various problems in children and

elderly adults. The strongest support exists for CBT of

anxiety disorders, somatoform disorders, bulimia, anger

control problems, and general stress. Eleven studies com-

pared response rates between CBT and other treatments or

control conditions. CBT showed higher response rates than

the comparison conditions in seven of these reviews and

only one review reported that CBT had lower response

rates than comparison treatments. In general, the evidence-

base of CBT is very strong. However, additional research is

needed to examine the efficacy of CBT for randomized-

controlled studies. Moreover, except for children and

elderly populations, no meta-analytic studies of CBT have

been reported on specific subgroups, such as ethnic

minorities and low income samples.

Keywords CBT � Efficacy � Meta-analyses � Comprehensive review

Introduction

Cognitive-behavioral therapy (CBT) refers to a class of

interventions that share the basic premise that mental dis-

orders and psychological distress are maintained by cogni-

tive factors. The core premise of this treatment approach, as

pioneered by Beck (1970) and Ellis (1962), holds that mal-

adaptive cognitions contribute to the maintenance of emo-

tional distress and behavioral problems. According to Beck’s

model, these maladaptive cognitions include general beliefs,

or schemas, about the world, the self, and the future, giving

rise to specific and automatic thoughts in particular situa-

tions. The basic model posits that therapeutic strategies to

change these maladaptive cognitions lead to changes in

emotional distress and problematic behaviors.

Since these early formulations, a number of disorder-

specific CBT protocols have been developed that specifi-

cally address various cognitive and behavioral maintenance

factors of the various disorders. Although these disorder-

specific treatment protocols show considerable differences

in some of the specific treatment techniques, they all share

the same core model and the general approach to treatment.

Consistent with the medical model of psychiatry, the

overall goal of treatment is symptom reduction, improve-

ment in functioning, and remission of the disorder. In order

to achieve this goal, the patient becomes an active partic-

ipant in a collaborative problem-solving process to test and

challenge the validity of maladaptive cognitions and to

S. G. Hofmann (&) � A. Asnaani � I. J. J. Vonk � A. T. Sawyer � A. Fang

Department of Psychology, Boston University, 648 Beacon St.,

6th floor, Boston, MA 02215, USA

e-mail: [email protected]

123

Cogn Ther Res (2012) 36:427–440

DOI 10.1007/s10608-012-9476-1

modify maladaptive behavioral patterns. Thus, modern

CBT refers to a family of interventions that combine a

variety of cognitive, behavioral, and emotion-focused

techniques (e.g., Hofmann 2011; Hofmann et al. in press).

Although these strategies greatly emphasize cognitive

factors, physiological, emotional, and behavioral compo-

nents are also recognized for the role that they play in the

maintenance of the disorder.

A recent review of meta-analyses of CBT identified 16

quantitative reviews that included 332 clinical trials cov-

ering 16 different disorders or populations (Butler et al.

2006). To our knowledge, this was the first review of meta-

analytic studies examining the efficacy of CBT for a

number of psychological disorders. This article has since

become one of the most influential reviews of CBT.

However, the search strategy was restrictive, because only

one meta-analysis was selected for each disorder. Fur-

thermore, the search only covered the period up to 2004,

but many reviews have been published since then. In fact,

the majority of studies (84 %) was published after 2004.

The goal of our review was to provide a comprehensive

survey of all contemporary meta-analyses examining the

evidence base for the efficacy of CBT to date. The meta-

analyses included in the present review were all judged to

be methodologically sound.

Methods

Search Strategy and Study Selection

To obtain the articles for this review, we searched PubMed,

PsychInfo, and Cochrane library databases. Searches were

conducted for studies published between the first available

year and January 26, 2012 using the following key words:

meta-analysis AND cognitive behav*, meta-analysis AND

cognitive therapy, quantitative review AND cognitive

behav*, quantitative review AND cognitive therapy. This

initial search yielded 1,163 hits, of which 355 were dupli-

cates and had to be excluded. The remaining 808 non-

duplicate articles were further examined to determine if

they met specific inclusionary criteria for the purposes of

this review. All included studies had to be quantitative

reviews (i.e., meta-analyses) of CBT. In order to limit this

review to contemporary studies, only articles published

since 2000 were included. The final sample included in this

review consisted of 269 meta-analyses (Fig. 1). Out of

those, we described a representative sample of 106 meta-

analytic studies. The complete reference list for the final

sample of included meta-analyses can be obtained by

accessing the webpage www.bostonanxiety.org/cbtreview.

html. As already noted, the majority (84 %) of these studies

was published after 2004, the most recent year covered by

the meta-analysis by Butler et al. (2006). The number of

meta-analytic reviews per year is depicted in Fig. 2.

Categorization of Meta-analyses

The 269 meta-analyses were categorized into groups to

provide the most meaningful and extensive examination of

the efficacy of CBT across a range of problem areas and

study populations. The major groupings were the follow-

ing: substance use disorder, schizophrenia and other psy-

chotic disorders, depression and dysthymia, bipolar

disorder, anxiety disorders, somatoform disorders, eating

disorders, insomnia, personality disorders, anger and

aggression, criminal behaviors, general stress, distress due

to general medical conditions, chronic pain and fatigue,

pregnancy complications and female hormonal conditions.

In addition, some meta-analyses specifically examined

CBT for disorders in children and elderly adults. For each

disorder and population grouping, data were described

qualitatively, considering the findings of all meta-analyses

within that group. The 269 meta-analyses included a wide

variety of studies that employed different methodologies

and effect size estimates. Therefore, we used the designa-

tion small, medium, and large for the magnitude of effect

sizes in our review of the 106 representative meta-analyses

(Cohen 1988). In addition, we provide reported response

rates, a widely accepted and common metric in psychiatry,

from a subsample of 11 studies that examined the efficacy

of CBT in randomized controlled trials.

Results

Addiction and Substance Use Disorder

There was evidence for the efficacy of CBT for cannabis

dependence, with evidence for higher efficacy of multi-session

CBT versus single session or other briefer interventions, and a

lower drop out rate compared to control conditions (Dutra et al.

2008). However, the effect size of CBT was small as compared

to other psychosocial interventions (e.g., contingency man-

agement, relapse prevention, and motivational approaches) for

substance dependence, and agonist treatments showed a

greater effect size than CBT in certain drug dependencies, such

as opioid and alcohol dependence (Powers et al. 2008b).

Treatments for smoking cessation found that coping

skills, which were partially based on CBT techniques, were

highly effective in reducing relapse in a community sample

of nicotine quitters (Song et al. 2010), and another meta-

analysis noted superiority of CBT (either alone or in com-

bination with nicotine replacement therapy) over nicotine

replacement therapy alone (Garcı́a-Vera and Sanz 2006).

Furthermore, there was evidence for superior performance of

428 Cogn Ther Res (2012) 36:427–440

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behavioral approaches in the treatment of problematic

gambling as compared to control treatments (Oakley-

Browne et al. 2000). One meta-analysis (Leung and Cottler

2009) reported larger effect sizes of CBT when this treatment

was grouped with other non-pharmacological treatments

(such as brief interventions) as compared to pharmacological

agents (e.g., naltrexone, carbamazepine, and topiramate),

but CBT was not more efficacious than these other briefer,

less expensive approaches.

Schizophrenia and Other Psychotic Disorders

Meta-analyses examining the efficacy of psychological

treatments for schizophrenia revealed a beneficial effect of

CBT on positive symptoms (i.e., delusions and/or halluci-

Studies initially identified (n=808, duplicates removed)

Excluded: Studies published before 2000

(n=38)

Addictions (n=18)

Anger or Aggression

(n=2)

Excluded: Not meta- analyses/not examining

CBT (n=501)

Anxiety Disorders

(n=48)

Bipolar Disorder (n=10)

Children (n=66)

Chronic Med Cond

(n=23)

Chronic Pain/Fatigue

(n=15)

Criminal Activity (n=7)

Depression (n=35)

Eating Disorders

(n=4)

Elderly Adults (n=10)

Insomnia (n=3)

Personality Disorders

(n=3)

Pregnancy or Female Hormonal Disorders (n=5)

Schizophrenia or Psychosis

(n=18)

Stress Management

(n=7)

Somatoform Disorders

(n=5)

Studies reporting response

(n = 11)

Studies retrieved for inclusion in study (n = 307)

Studies included in final review (n=269)

Further divided into 17 disorder/population categories

rates

Fig. 1 Flow diagram showing

effects of inclusionary and

exclusionary criteria on final

sample selection

Fig. 2 Number of meta-analyses published by year since 2000. Note

that the number of studies corresponding to 2011 only covered studies

until September of that year

Cogn Ther Res (2012) 36:427–440 429

123

nations) of schizophrenia (e.g., Gould et al. 2001; Rector

and Beck 2001). There was also evidence (e.g., Zimmer-

mann et al. 2005) that CBT is a particularly promising

adjunct to pharmacotherapy for schizophrenia patients who

suffer from an acute episode of psychosis rather than a

more chronic condition.

CBT appeared to have little effect on relapse or hospital

admission compared to other interventions, such as early

intervention services or family intervention (e.g., Bird et al.

2010; Álvarez-Jiménez et al. 2011). However, CBT had a

beneficial effect on secondary outcomes. For example, a

more recent meta-analysis by Wykes et al. (2008) exam-

ined controlled trials of CBT for schizophrenia and con-

firmed findings from previous meta-analyses (e.g., Gould

et al. 2001; Rector and Beck 2001), suggesting that CBT

had a small to medium effect size as compared to control

conditions on both positive and negative symptoms. In

addition, this meta-analysis revealed medium effect sizes

for improvements in secondary outcomes that were not the

direct targets of treatment, including general functioning,

mood, and social anxiety.

Depression and Dysthymia

CBT for depression was more effective than control condi-

tions such as waiting list or no treatment, with a medium

effect size (van Straten et al. 2010; Beltman et al. 2010).

However, studies that compared CBT to other active treat-

ments, such as psychodynamic treatment, problem-solving

therapy, and interpersonal psychotherapy, found mixed

results. Specifically, meta-analyses found CBT to be equally

effective in comparison to other psychological treatments

(e.g., Beltman et al. 2010; Cuijpers et al. 2010; Pfeiffer et al.

2011). Other studies, however, found favorable results for

CBT (e.g., Di Giulio 2010; Jorm et al. 2008; Tolin 2010). For

example, Jorm et al. (2008) found CBT to be superior to

relaxation techniques at post-treatment. Additionally, Tolin

(2010) showed CBT to be superior to psychodynamic ther-

apy at both post-treatment and at 6 months follow-up,

although this occurred when depression and anxiety symp-

toms were examined together.

Compared to pharmacological approaches, CBT and

medication treatments had similar effects on chronic

depressive symptoms, with effect sizes in the medium-large

range (Vos et al. 2004). Other studies indicated that phar-

macotherapy could be a useful addition to CBT; specifically,

combination therapy of CBT with pharmacotherapy was

more effective in comparison to CBT alone (Chan 2006).

Bipolar Disorder

Meta-analyses examining the efficacy of CBT for bipolar

disorder revealed small to medium overall effect sizes of

CBT at post-treatment, with effects typically diminishing

slightly at follow-up. These findings emerged from exam-

inations of both manic and depressive symptoms associated

with bipolar disorder (e.g., Gregory 2010a, b). There is

little evidence that CBT as a stand-alone treatment (rather

than as an adjunct to pharmacotherapy) is effective for the

treatment of bipolar disorder.

In addition to examining CBT for attenuating symptoms

of bipolar disorder, some meta-analyses focused on the

efficacy of CBT for preventing relapse in bipolar patients.

One study (Beynon et al. 2008) examined the efficacy of

CBT for preventing relapse and found it to be somewhat

effective when comparing CBT versus treatment as usual.

Overall, CBT for bipolar disorder was an effective method

of preventing or delaying relapses (e.g., Lam et al. 2009;

Cakir and Ozerdem 2010). Furthermore, the efficacy of

CBT at preventing relapse did not seem to be influenced by

the number of previous manic or depressive episodes.

Anxiety Disorders

In general, CBT is a reliable first-line approach for treat-

ment of this class of disorders (Hofmann and Smits 2008),

with support for significant positive effects of CBT on

secondary symptoms such as sleep dysfunction and anxiety

sensitivity (Ghahramanlou 2003). Further, internet-deliv-

ered or guided self-help CBT showed some promise in

immediate symptom relief as compared to no treatment,

but the long-term maintenance with this modality of CBT

remains unclear (Öst 2008; Coull and Morris 2011).

CBT for social anxiety disorder evidenced a medium to

large effect size at immediate post-treatment as compared

to control or waitlist treatments, with significant mainte-

nance and even improvement of gains at follow-up (Gil

et al. 2001). Further, exposure, cognitive restructuring,

social skills training and both group/individual formats

were equally efficacious (Powers et al. 2008a), with

superior performance over psychopharmacology in the

long term (Fedoroff and Taylor 2001). Similarly, intero-

ceptive exposure for treatment of panic disorder was

moderately effective and superior to control/pill placebo

treatments and applied relaxation (Haby et al. 2006;

Furukawa et al. 2007). For panic disorder without agora-

phobia, combination treatment of CBT and applied relax-

ation was equal in efficacy to use of either therapy

approach alone, and use of either or both were superior to

use of medications (Mitte 2005).

Various CBT techniques for specific phobia (systematic

desensitization, exposure, cognitive therapy) were as effec-

tive as applied relaxation and applied tension, producing

effect sizes in the large range, with long-term maintenance of

gains (Ruhmland and Margraf 2001). For generalized anxi-

ety disorder, CBT was superior as compared to control or pill

430 Cogn Ther Res (2012) 36:427–440

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placebo conditions, and equally efficacious as relaxation

therapy, supportive therapy, or psychopharmacology, but

less efficacious in comparison to attention placebos and in

those with more severe generalized anxiety disorder

symptoms.

CBT for post-traumatic stress disorder was equal in

efficacy to eye movement desensitization and reprocessing

(Bisson et al. 2007), with both being superior to treatment

as usual, waitlist, or other treatments (such as supportive

counseling) for post-traumatic stress disorder (Bisson and

Andrew 2008). However, it is questionable whether the

eye-movement technique is an active treatment ingredient.

Clinical trials also revealed a large effect size for CBT

and/or exposure response prevention for obsessive com-

pulsive disorder, with evidence suggesting that a combi-

nation of in vivo and imaginal exposures outperformed the

use of only in vivo exposures (Ruhmland and Margraf

2001). Furthermore, CBT was found to be similarly effi-

cacious than clomipramine and selective reuptake inhibi-

tors (Eddy et al. 2004).

Somatoform Disorders

Within the somatoform disorders category of DSM-IV,

meta-analyses primarily examined the efficacy of psycho-

logical interventions for hypochondriasis and body dys-

morphic disorder. One meta-analysis found a large mean

effect size for CBT, which outperformed other psycho-

logical treatments (i.e., psychoeducation, explanatory

therapy, cognitive therapy, exposure and response pre-

vention, and behavioral stress management), with effect

sizes in the large range, as well as pharmacotherapy

treatments (paroxetine, fluoxetine, fluvoxamine, and ne-

fazodone), which also evidenced large effect sizes (Taylor

et al. 2005). The mean effect size for control conditions

(e.g., wait-list control) was small. These results were par-

tially supported by other evidence, as a more recent meta-

analysis found superior outcomes of CBT for hypochon-

driasis compared to waiting list control, usual medical care

or placebo at 12-months follow-up (Thomson and Page

2007). However, this meta-analysis also found no differ-

ences between CBT and waiting list/placebo at post-

treatment.

Meta-analyses comparing the efficacy of CBT to control

treatments found that CBT was superior in significantly

reducing body dysmorphic disorder symptoms (Ipser et al.

2009). In comparing relative efficacy of CBT versus

pharmacotherapy, effect sizes were large on body dys-

morphic disorder severity measures for CBT, and ranged

from medium to large for pharmacotherapy (Williams et al.

2006). In addition, another meta-analysis found that CBT

for body image disturbances was effective, with effect sizes

ranging from medium to large (Jarry and Ip 2005).

Eating Disorders

For bulimia nervosa, meta-analyses compared the efficacy

of CBT to control treatments and found effect sizes in the

medium range (Thompson-Brenner 2003). However, the

effect of behavior therapy was greater than that of CBT,

with the average effect size for behavior therapy in the

large range (Thompson-Brenner 2003). Another meta-

analysis comparing CBT with control treatments found

remission response rates to be higher for CBT, with a

medium relative risk ratio (Hay et al. 2009). When com-

paring CBT to other psychotherapies, specifically, inter-

personal therapy, dialectical behavioral therapy, hypno-

behavioral therapy, supportive psychotherapy, behavioral

weight loss treatment, and self-monitoring, CBT fared

significantly better in remission response rates for bulimia

nervosa, with a large relative risk ratio (Hay et al. 2009).

For binge eating disorder, a recent meta-analysis found

that psychotherapy and structured self-help yielded large

effect sizes, when compared to pharmacotherapy, which

yielded medium effect sizes (Vocks et al. 2010). Although

this study did not parse out the efficacy of CBT specifi-

cally, a majority of the included trials for psychotherapy

involved CBT (19 out of 23 trials). Furthermore, a review

and meta-analysis by Reas and Grilo (2008) suggested that

combination treatment of psychotherapy and medications

did not enhance binge-eating outcomes, but may have

enhanced weight loss outcomes.

Insomnia

CBT for insomnia (CBT-I) has long been shown to be more

efficacious than control treatments. A recent meta-analysis

examined its efficacy on both subjective and objective

sleep parameters in comparison to a control group for

individuals with primary insomnia (Okajima et al. 2011).

Effect sizes for the efficacy of CBT-I versus control at the

end of treatment on subjective sleep measures, which

included sleep onset latency, total sleep time, wake after

sleep onset, total wake time, time in bed, early morning

awakening, and sleep efficiency, ranged from minimal

(total sleep time) to large (early morning awakening;

Okajima et al. 2011). For objective measures using a pol-

ysomnogram or actigraphic evaluation, effect sizes ranged

from small (total sleep time) to large (total wake time;

Okajima et al. 2011). These findings were consistent with

results from another meta-analysis, which examined the

relative efficacy of behavioral interventions for insomnia

including CBT, relaxation, and only behavioral techniques

(Irwin et al. 2006). This study reported effect sizes ranging

from -.75 to 1.47 for CBT, -.60–.53 for relaxation tech-

niques, and -.82–.91 for only behavioral techniques on

subjective sleep outcomes.

Cogn Ther Res (2012) 36:427–440 431

123

Personality Disorders

There was one meta-analysis that examined the relative

efficacy of CBT versus psychodynamic therapy for the

treatment of personality disorders (Leichsenring and Lei-

bing 2003). The findings indicated a larger overall effect

size for psychodynamic therapy compared to CBT. This

was consistent with observer-rated measures, which

showed a similar pattern of effect sizes: stronger for psy-

chodynamic therapy than for CBT (although this effect size

was also large). Self-report measures, however, indicated

larger effect sizes for CBT than for psychodynamic

therapy.

Another meta-analysis compared the efficacy of eleven

different psychological therapies, including CBT, for

antisocial personality disorder (Gibbon et al. 2010). Results

suggested that compared to control treatment, CBT plus

standard maintenance was more efficacious in terms of

leaving the study early and cocaine use for outpatients with

antisocial personality disorder and comorbid cocaine

dependence. However, CBT plus treatment as usual was

not better than a control condition for these antisocial

personality disorder patients with regard to levels of recent

verbal or physical aggression. The relative efficacy of

psychological treatments for borderline personality disor-

der, in particular, was also examined, which yielded no

differences between dialectical behavioral therapy and

treatment as usual in individuals meeting criteria for bor-

derline personality disorder at 6 months, or in hospital

admissions in the previous 3 months (Binks et al. 2006).

Anger and Aggression

Two meta-analytic reviews focused on anger control

problems and aggression (Del Vecchio and O’Leary 2004;

Saini 2009). The findings from these meta-analyses sug-

gested that CBT is moderately effective at reducing anger

problems. Findings from these reviews also suggested that

CBT may be most effective for patients with issues

regarding anger expression.

CBT produced medium effect sizes as compared to other

psychosocial treatments and control conditions across the

two reviews that conducted quantitative analyses. A meta-

analysis on the effectiveness of anger treatments for spe-

cific anger problems (Del Vecchio and O’Leary 2004)

included only studies in which subjects met clinically

significant levels of anger on standardized anger mea-

surements prior to treatment. This meta-analysis examined

the effects of CBT, cognitive therapy, relaxation, and

‘other’ (e.g., social skills training, process group counsel-

ing) on various anger problems including driving anger,

anger suppression, and anger expression difficulties.

Criminal Behaviors

Four separate meta-analytic studies supported the efficacy

of CBT for criminal offenders (Illescas et al. 2001; Lösel

and Schmucker 2005; Pearson et al. 2002; Wilson et al.

2005). Out of several theoretical orientations and types of

psychological interventions for criminal activity, behavior

therapy and CBT appeared to be the superior interventions

in reducing recidivism rates, both with medium mean

effect sizes (Illescas et al. 2001). Effect sizes for other

interventions ranged from small to medium (Illescas et al.

2001). Another study demonstrated consistent findings with

a small weighted mean effect size of behavior therapy or

CBT for reducing recidivism (Pearson et al. 2002). Simi-

larly, Wilson et al. (2005) found an overall small-to-med-

ium mean effect size for CBT programs for convicted

offenders.

For sexual offenders in particular, physical treatments,

such as surgical castration and hormonal treatment, were

demonstrated to have greater efficacy in reducing sexual

recidivism in comparison to CBT, with large significant

odds ratios for both of these alternative interventions

(Lösel and Schmucker 2005). Of the various psychological

interventions for sexual offenders, however, classical

behavioral and CBT approaches indicated the strongest

efficacy, with odds ratios in the medium to large range

(Lösel and Schmucker 2005) as compared to insight-ori-

ented and therapeutic community interventions.

A study of CBT for domestic violence indicated no

differences between CBT and the Duluth model (which

is based on a feminist psycho-educational approach) for

treating domestically violent males (Babcock et al.

2004). The aggregated data from experimental and quasi-

experimental studies showed that CBT had an overall

small effect size, and the Duluth model had an overall

slightly larger, but still small effect size (Babcock et al.

2004).

General Stress

Four meta-analyses examined occupational stress and the

majority of their results were quite similar: CBT interven-

tions were more effective in comparison to other intervention

types such as organization focused therapies, especially

when CBT focused on psycho-social outcomes in employees

(Kim 2007; Richardson and Rothstein 2008; van der Klink

et al. 2001). For example, Richardson and Rothstein (2008)

found CBT alone to be more effective in comparison to CBT

combined with additional psychological components. These

studies found a large effect size for overall CBT interven-

tions, large effect size for single-mode CBT interventions,

and small effect size for CBT interventions with four or more

components. In contrast, Marine et al. (2006) chose not to

432 Cogn Ther Res (2012) 36:427–440

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compare CBT with other interventions, such as relaxation

techniques for psychological stress, because most interven-

tions comprised both elements and could not be evaluated

separately. With respect to stress in parents of children with

developmental disabilities, positive effects were found for

CBT, but the effect size was relatively small (Singer et al.

2007). In contrast to the results of Richardson and Rothstein

(2008), this meta-analysis found multiple component inter-

ventions which combined CBT, behavioral parent training

and in some cases other forms of support services, to have a

higher and large effect size in comparison to CBT alone

(Singer et al. 2007).

Distress due to General Medical Conditions

Limited well-controlled studies existed in the study of

non-ulcer dyspepsia, multiple sclerosis, physical disability

following traumatic injury, non-epileptic seizures, post-

concussion syndrome, chronic obstructive pulmonary

disease, hypertension, Type II diabetes, and burning

mouth syndrome (e.g., Soo et al. 2004; Thomas et al.

2006; Baker et al. 2007; Ismail et al. 2004). However,

cancer was studied more rigorously and with more robust

methodological attention, indicating small to medium

effect sizes of individual CBT as compared to patient

education only in gynecological and head/neck cancers

(Zimmermann and Heinrichs 2006; Luckett et al. 2011),

on secondary outcomes such as quality of life, psycho-

logical distress (i.e., depression and anxiety), and pain.

Further, CBT was shown to be equally effective as

exercise interventions in treating cancer-related fatigue

(Kangas et al. 2008).

Small to medium effect sizes were observed in treatment

of secondary symptoms (anxiety and stress) experienced by

individuals who were HIV positive, with particular efficacy

(particularly for stress management) in reducing anger

symptoms as compared to supportive therapy (Crepaz et al.

2008), but not for outcomes such as low cell count, med-

ication adherence, or when used with marginalized popu-

lations such as ethnic minorities and women (Crepaz et al.

2008; Rueda et al. 2006).

CBT was shown to be superior in the treatment of sec-

ondary symptoms of spinal cord injury as compared to

controls in assertiveness skills, coping, depression and

quality of life (Dorstyn et al. 2011), better than placebo or

diet/exercise alone (Shaw et al. 2005), but equal to yoga/

education in depressive symptoms (Martinez-Devesa et al.

2010). CBT was only slightly more effective than usual

care or waitlist condition in the treatment of irritable bowel

syndrome, with peppermint oil having greater efficacy in

providing relief in this particular disorder (Enck et al.

2010).

Chronic Pain and Fatigue

Meta-analyses examining the efficacy of psychosocial

treatments for chronic pain have investigated chronic low

back pain, fibromyalgia, rheumatoid arthritis, chronic

fatigue syndrome, chronic musculoskeletal pain, and non-

specific chest pain. These reviews have examined the effect

of a range on treatments on chronic pain, including relax-

ation techniques, mindfulness-based techniques, accep-

tance-based techniques, biofeedback, psycho-education,

and behavioral and cognitive-behavioral treatments.

Results of these meta-analyses revealed varying effect

sizes for these treatments depending on the type of chronic

pain targeted; however, CBT treatments for chronic pain

were consistently in the small to medium effect size range.

Similar results were found in a meta-analysis examining

psychological treatments for fibromyalgia (Glombiewski

et al. 2010). This meta-analysis revealed that CBT was

superior to other psychological treatments for decreasing

pain intensity. Pre-post analyses revealed a medium effect

size for CBT as compared to a small effect size for all other

psychological treatments combined (excluding CBT). CBT

treatments for chronic fatigue syndrome were moderately

effective (e.g., Malouff et al. 2008; Price et al. 2008).

Malouff et al. (2008) conducted a meta-analysis revealing a

medium effect size in post-treatment fatigue for partici-

pants receiving CBT versus those in control conditions.

Pregnancy Complications and Female Hormonal

Conditions

One meta-analysis found CBT to be more effective in com-

parison to control conditions for perinatal depression (Sockol

et al. 2011), and another meta-analysis found beneficial effects

of CBT for postnatal depression, but these results need to be

interpreted with caution because it is difficult to causally link

depression with pregnancy and hormonal changes in these

studies (Dennis and Hodnett 2007). Further, Bledsoe and

Grote (2006) found greater decreases in depression for women

experiencing non-psychotic major depression in pregnancy

and postnatal periods treated with combination treatment in

comparison to antidepressant medication alone, which was

itself more effective in comparison to CBT alone. The effect

size for postnatal treatments was large in comparison to the

small to medium effects of prenatal treatments, but when

pharmacological treatments were excluded, the effect size for

postnatal treatments decreased to the medium range.

For the treatment of premenstrual syndrome, Busse et al.

(2009) found that CBT significantly reduced depressive

and anxiety symptoms associated with this syndrome, as

indicated by a medium effect size. Once again, these results

need to be interpreted carefully due to the small number of

well-controlled studies on which these reviews were based.

Cogn Ther Res (2012) 36:427–440 433

123

CBT for Special Populations

Children

Within internalizing symptoms, there was support for the

preferential use of CBT approaches in treatment of anxiety

disorders in children and adolescents, with effect sizes in the

large range (Santacruz et al. 2002; James et al. 2005). Further,

CBT treatment for obsessive compulsive disorder as com-

pared to alternative approaches (no treatment, other psycho-

social treatments and medications such as clomipramine and

fluvoxamine) resulted in significantly better outcomes (Phil-

lips 2003; Guggisberg 2005). The data supporting CBT for

depression was less strong, but still in the medium effect size

range across meta-analyses, with maintenance in 6-months

follow-up periods (Santacruz et al. 2002). In addition, CBT

seemed to work equally well as other psychotherapies (i.e.,

interpersonal therapy and family systems therapy), but was

regarded as superior to selective reuptake inhibitors due to

reduced chance of side effects and greater cost effectiveness

(Haby et al. 2004). The studies on efficacy of CBT for

addressing suicidal behaviors were scarce (Robinson et al.

2011), and warrant further investigation.

The picture was more mixed for other disorders, with

CBT showing equal efficacy in reducing disruptive class-

room behaviors and aggressive/antisocial behaviors, as

other psychosocial treatments, better efficacy as compared

to no treatment or treatment as usual, and less efficacy than

pharmacological approaches (Lösel and Beelmann 2003;

Özabaci 2011). Similarly, CBT for attention deficit

hyperactivity disorder showed some efficacy, but was not

superior to medications (Van der Oord et al. 2008). The

efficacy of behavioral techniques (e.g., motivational

enhancement and behavioral contingencies) was small to

medium for the treatment of adolescent smoking and sub-

stance use as compared to no treatment, but not more so

than other psychotherapies. In addition, there was a med-

ium to large effect size of CBT over waitlist across meta-

analyses examining chronic headache pain. Finally, the

data on efficacy for CBT in juvenile sex offenders, child-

hood sexual abuse survivors, childhood obesity, fecal

incontinence, and juvenile diabetes was limited, showing

preliminary support for CBT as compared to no treatment,

but equal efficacy to other psychosocial approaches

(Walker et al. 2005; Macdonald et al. 2006).

Elderly Adults

With respect to mood disorders, with depression as the

most commonly examined disorder, nearly all meta-anal-

yses showed that CBT was more effective than waiting list

control conditions, but equally effective in comparison to

other active treatment methods, such as reminiscence, (an

intervention that uses recall of past events, feelings and

thoughts to facilitate pleasure, quality of life or adaptation

to the present; Peng et al. 2009), psychodynamic therapy,

and interpersonal therapy (Krishna et al. 2011; Wilson

et al. 2008). Pinquart et al. (2007), however, found a large

effect size for CBT, whereas the effect sizes for the other

active treatment conditions were in the medium-large

range. When long-term outcomes were examined, results

of one meta-analysis indicated that treatment gains of CBT

for depression were maintained at 11-months follow-up

(Krishna et al. 2011), but long-term follow-up data

remained scarce in the other meta-analyses. In a meta-

analysis assessing the additive effects of CBT and phar-

macological approaches, Peng et al. (2009) found that CBT

was more effective in comparison to placebo, but CBT as

an adjunct to antidepressant medication did not increase the

effectiveness of antidepressants in this population.

For anxiety disorders in the elderly, CBT (alone or

augmented with relaxation training) did not enhance out-

comes beyond relaxation training alone (Thorp et al. 2009),

although many of these studies were uncontrolled. In

contrast to the findings by Thorp et al. (2009), Hendriks

et al. (2008) found that anxiety symptoms were signifi-

cantly decreased following CBT than after either a waiting-

list control condition or other treatment methods. Addi-

tionally, CBT significantly alleviated accompanying

symptoms of worry and depression when compared to

waiting-list control or an active control condition.

Response Rates of Randomized Controlled Studies

The meta-analytic studies that provided response rates are

listed in Table 1. The response rates of CBT varied

between 38 % for treating obsessive compulsive disorder

(Eddy et al. 2004) and 82 % for treating body dysmorphic

disorder (Ipser et al. 2009). In contrast, the response rates

of the waitlist groups ranged from 2 % for the treatment of

bulimia nervosa (Thompson-Brenner 2003) to 14 % for

generalized anxiety disorder (Hunot et al. 2007). CBT also

demonstrated higher response rates in comparison to

treatment as usual in treatment of generalized anxiety

disorder and chronic fatigue (Price et al. 2008), and higher

or equal response rates as compared to other therapies or

psychopharmacological interventions in most studies. CBT

only produced a lower response rate than psychodynamic

therapy for the personality disorders (47 vs. 59 %; Leich-

senring and Leibing 2003).

Discussion

CBT is arguably the most widely studied form of psy-

chotherapy. We identified 269 meta-analytic reviews that

434 Cogn Ther Res (2012) 36:427–440

123

examined CBT for a variety of problems, including sub-

stance use disorder, schizophrenia and other psychotic

disorders, depression and dysthymia, bipolar disorder,

anxiety disorders, somatoform disorders, eating disorders,

insomnia, personality disorders, anger and aggression,

criminal behaviors, general stress, distress due to general

medical conditions, chronic pain and fatigue, distress

related to pregnancy complications and female hormonal

conditions. Additional meta-analytic reviews examined the

efficacy of CBT for various problems in children and

elderly adults. The vast majority of studies (84 %) was

published after 2004, which was the last year of coverage

of the review by Butler et al. (2006), making the present

study the most comprehensive and contemporary review of

meta-analytic studies of CBT to date.

For the treatment of addiction and substance use dis-

order, the effect sizes of CBT ranged from small to med-

ium, depending on the type of the substance of abuse. CBT

was highly effective for treating cannabis and nicotine

dependence, but less effective for treating opioid and

alcohol dependence. For treating schizophrenia and other

psychotic disorders, the empirical literature suggested

appreciable efficacy of CBT particularly for positive

symptoms and secondary outcomes in the psychotic dis-

orders, but lesser efficacy than other treatments (e.g.,

family intervention or psychopharmacology) for chronic

symptoms or relapse prevention.

The meta-analytic literature on the efficacy of CBT for

depression and dysthymia was mixed with some studies

suggesting strong evidence and others reporting weak

support. Some authors have suggested that the strong

effects in some studies may be an overestimation due to a

publication bias (Cuijpers et al. 2010). Similarly, the effi-

cacy of CBT for bipolar disorder was small to medium in

the short-term in comparison to treatment as usual. How-

ever, there was limited evidence for the superiority of CBT

alone over pharmacological approaches; for the treatment

of depressive symptoms in bipolar disorder, the use of CBT

was well supported. However, the long-term superiority

compared to other treatments is still uncertain.

The efficacy of CBT for anxiety disorders was consis-

tently strong, despite some notable heterogeneity in the

specific anxiety pathology, comparison conditions, follow-

up data, and severity level. Large effect sizes were reported

for the treatment of obsessive compulsive disorder, and at

least medium effect sizes for social anxiety disorder, panic

disorder, and post-traumatic stress disorder. Medium to

large CBT treatment effects were reported for somatoform

disorders, such as hypochondriasis and body dysmorphic

disorder. However, more studies using larger trials and

Table 1 Pooled meta-analytic response rates for CBT versus other conditions across disorders

Disorder Author (year) Number of

studies

CBT

(%)

MED OT

(%)

PBO

(%)

TAU

(%)

WL

(%)

Comparison

Boderline personality

disorder

Ipser et al. (2009) 2 82a 56 %a 18a CBT, MED [ PBO

Panic disorder Siev and Chambless

(2008)

5 77 – 50 – – – CBT [ OT

Anger/aggression Del Vecchio and

O’Leary (2004)

23 66–69 – 65–70 – – – CBT = OT

Depression Leichsenring (2001) 6 51–87 – 45–70 – – – CBT [ OT

Childhood anxiety James et al. (2005) 13 56 – – 28b – – CBT [ PBO

Chronic fatigue Malouff et al. (2008) 5 50 – – – – – –

Personality disorders Leichsenring and

Leibing (2003)

25 47c – 59d – – – CBT \ OT

Generalized anxiety

disorder

Hunot et al. (2007) 8 46e – – – 14 14 CBT = OT;

CBT [ TAU,WL

Chronic fatigue Price et al. (2008) 6 40 – – – 26 – CBT [ TAU

Bulimia nervosa Thompson-Brenner

(2003)

26 40–44 – – 27 – 2 CBT [ PBO, WL

Obsessive compulsive

disorder

Eddy et al. (2004) 3 38–50 – – – – – –

The table shows response rate percentages for CBT (from highest to lowest) compared to each comparison condition for every meta-analaytic

study reporting such data across disorder groups; –: no data reported;[: higher efficacy;\: lower efficacy; =: equal efficacy. MED medication/

pharmacological approaches, OT other therapies (consisting of relaxation therapy, supportive therapy, or psychodynamic therapy), PBO placebo/

control treatments, TAU treatment as usual, WL waitlist treatment, BDD body dysmorphic disorder, PD panic disorder without agoraphobia, GAD generalized anxiety disorder, OCD obsessive–compulsive disorder. aOne study; bHeterogeneous response rate pooling placebo/control, waitlist,

and supportive treatment conditions; c11 studies; d14 studies; eResponse rate of OT not reported in paper; stated as being equal to CBT

(as indicated in comparison column)

Cogn Ther Res (2012) 36:427–440 435

123

greater sample sizes are needed to draw more conclusive

findings with regard to CBT’s relative efficacy in com-

parison to other active treatments.

For the treatment of bulimia, CBT was considerably

more effective than other forms of psychotherapies, but

less is known for other eating disorders. Similarly, CBT

demonstrated superior efficacy as compared to other

interventions for treating insomnia when examining sleep

quality, total sleep time, waking time, and sleep efficiency

outcomes. However, although there were small effects of

CBT for sleep problems among older adults (aged 60?),

these effects may not be long lasting (Montgomery and

Dennis 2009).

For personality disorders, there was some evidence for

superior efficacy of CBT as compared to other psychoso-

cial treatments for the personality disorders. However, the

studies showed considerable variation in measurement

methods, comorbid disorders, and demographic variables.

CBT also produced medium to large effect sizes for

treating anger and aggression (e.g., Saini 2009), although a

greater number of well-controlled studies are needed to

more adequately parse out the specific efficacy of CBT

compared to the psychosocial treatments for anger on the

whole. Similarly, more studies are needed before any firm

conclusions can be drawn about the efficacy of this treat-

ment for criminal behaviors.

As a stress management intervention, CBT was more

effective that other treatments, such as organization-

focused therapies. However, more research on the long-

term effects of CBT for occupational stress is needed.

Furthermore, there are open questions about the relative

efficacy of CBT versus pharmacological approaches to

stress management. Similarly, several common concerns

recurred across meta-analytic examinations of CBT for

chronic medical conditions, chronic fatigue and chronic

pain, namely: (1) a scarcity of studies and small sample

sizes; (2) poor methodological design of studies that are

included in meta-analyses; and (3) grouping of CBT with a

host of other psychotherapies (such as psychodynamic

therapy, hypnotherapy, mindfulness, relaxation, and sup-

portive counseling), which made it difficult to parse out

whether there are any superior effects of CBT in the

majority of medical conditions examined.

There was preliminary evidence for CBT for treating

distress related to pregnancy complications and female

hormonal conditions. However, more research is needed

due to a scarcity of follow-up data and low quality studies.

This appeared to be a highly promising area for CBT given

that the alternative—pharmacological treatments—can be

associated with serious risks of adverse effects for pregnant

women and breastfeeding mothers.

In our review of meta-analyses, CBT tailored to children

showed robust support for treating internalizing disorders,

with benefits outweighing pharmacological approaches in

mood and anxiety symptoms. The evidence was more

mixed for externalizing disorders, chronic pain, or prob-

lems following abuse. Moreover, there remains a need for a

greater number of high-quality trials in demographically

diverse samples. Similarly, CBT was moderately effica-

cious for the treatment of emotional symptoms in the

elderly, but no conclusions about long-term outcomes of

CBT or combination therapies consisting of CBT, and

medication could be made.

Finally, our review identified 11 studies that compared

response rates between CBT and other treatments or con-

trol conditions. In seven of these reviews, CBT showed

higher response rates than the comparison conditions, and

in only one review (Leichsenring and Leibing 2003), which

was conducted by authors with a psychodynamic orienta-

tion, reported that CBT had lower response rates than

comparison treatments.

In sum, our review of meta-analytic studies examining

the efficacy of CBT demonstrated that this treatment has

been used for a wide range of psychological problems. In

general, the evidence-base of CBT is very strong, and

especially for treating anxiety disorders. However, despite

the enormous literature base, there is still a clear need for

high-quality studies examining the efficacy of CBT. Fur-

thermore, the efficacy of CBT is questionable for some

problems, which suggests that further improvements in

CBT strategies are still needed. In addition, many of the

meta-analytic studies included studies with small sample

sizes or inadequate control groups. Moreover, except for

children and elderly populations, no meta-analytic studies

of CBT have been reported on particular subgroups, such

as ethnic minorities and low income samples.

Despite these weaknesses in some areas, it is clear that

the evidence-base of CBT is enormous. Given the high

cost-effectiveness of the intervention, it is surprising that

many countries, including many developed nations, have

not yet adopted CBT as the first-line intervention for

mental disorders. A notable exception is the Improving

Access to Psychological Therapies initiative by the

National Health Commissioning in the United Kingdom

(Rachman and Wilson 2008). We believe that it is time that

others follow suit.

Acknowledgments The authors would like to acknowledge the

following research assistants who provided crucial and much-appre-

ciated assistance with background literature reviews, initial identifi-

cation of articles, and obtained articles for use by the authors: Dan

Brager, Rachel Kaufmann, Rebecca Grossman, and Brian Hall. This

study was partially supported by NIMH grants MH-078308 and

MH-081116 awarded to Dr. Hofmann and MH-73937.

Conflict of interest Dr. Hofmann is a paid consultant of Merck

Pharmaceutical (Schering-Plough) for work unrelated to this

study.

436 Cogn Ther Res (2012) 36:427–440

123

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